<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606459
Report Date: 12/01/2023
Date Signed: 12/01/2023 01:17:05 PM


Document Has Been Signed on 12/01/2023 01:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:WESTWOOD MANORFACILITY NUMBER:
197606459
ADMINISTRATOR:NELLI KHLEBNIKOVAFACILITY TYPE:
740
ADDRESS:1539 MIDVALE AVETELEPHONE:
(323) 401-8622
CITY:LOS ANGELESSTATE: CAZIP CODE:
90024
CAPACITY:6CENSUS: 6DATE:
12/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:09 AM
MET WITH:Natalya Vydrug, AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/01/2023 at 8:10 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – Annual Inspection and met with Staff#1. Six (6) residents and five (5) staff were present during this inspection. Licensee and Administrator joined LPA after the facility tour but during record and file review.

Facility is licensed to serve six (6) non-ambulatory residents and approved hospice waiver for one (1) resident. The facility currently has 6 non-ambulatory residents. No residents are currently receiving Hospice services and 1 resident is receiving Home Health Services.

The home consists of 6 resident bedrooms, 3 bathrooms, living room, kitchen, dining room, laundry room, shaded front porch and backyard seating.

Staff#1 accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises.

Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, hot water temperature properly measured between 105 - 109 degrees F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Common areas were clean and clear of hazards, doorways were free of obstructions.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxics were kept in locked storage cabinet. First Aid kit was available. Three fire extinguishers last serviced July 18, 2023 was observed. Carbon monoxide detectors and smoke detectors are both functional.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: WESTWOOD MANOR
FACILITY NUMBER: 197606459
VISIT DATE: 12/01/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Five staff records were reviewed, 5 out of 5 staff records had current first aid certificates and had required criminal record clearances. Three staff were interviewed.

Five resident records were reviewed and, 5 out of 5 client records had Admission Agreements, and Medical Assessments. Two medication records were reviewed with the Administrator. Two residents were interviewed.

No deficiencies are being cited.

An exit interview was conducted and technical assistance provided. A copy of this report was discussed and left with the Administrator Natalya Vydrug.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 7